NCLEX NCLEX-PN
2024 Nclex Questions
1. A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?
- A. She dresses herself
- B. She pulls a toy behind her
- C. She can build a tower of eight blocks
- D. She can copy a horizontal or vertical line
Correct answer: She pulls a toy behind her
Rationale: The correct answer is 'She pulls a toy behind her.' This behavior is consistent with the developmental stage of an 18-month-old who enjoys push-pull toys. Dressing oneself usually begins around 3 years old, building a tower of eight blocks at approximately 3 years old, and copying a horizontal or vertical line at about 4 years old. Choices A, C, and D are incorrect as they represent skills that are typically observed in older children.
2. A health care worker is concerned about a new mother being overwhelmed by caring for her infant. What should the health care worker do?
- A. Immediately contact child protective services.
- B. Provide the mother with literature about child care.
- C. Consult a therapist to help the mother work out her fears.
- D. Refer the mother to parenting classes.
Correct answer: Refer the mother to parenting classes.
Rationale: When a health care worker is concerned about a new mother being overwhelmed by caring for her infant, the best course of action is to refer the mother to parenting classes. Prevention of child abuse is focused on educating parents on how to care for their child and handle the demands of infant care. By attending parenting classes, the mother can build self-confidence, self-esteem, and coping skills. Parenting classes help parents understand the developmental needs of their children and learn effective ways to manage their home environment. Additionally, these classes provide parents with increased social contacts and knowledge about community resources. Contacting child protective services (choice A) should not be the immediate action as there is no indication of abuse. Providing literature about child care (choice B) may not be as effective as hands-on parenting classes. Consulting a therapist (choice C) may be beneficial, but addressing parenting skills through classes is more appropriate in this scenario.
3. The licensed practical nurse assigned to the postpartum unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?
- A. A gravida IV para 3 that is Rh negative with an Rh-positive baby
- B. A gravida I para 1 that is Rh negative with an Rh-positive baby
- C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
- D. A gravida IV para 2 that is Rh negative with an Rh-negative baby
Correct answer: A gravida IV para 2 that is Rh negative with an Rh-negative baby
Rationale: The mothers in answers A, B, and C all require RhoGam as they are Rh negative with an Rh-positive baby or have experienced a stillbirth delivery, making them candidates for RhoGam injection. The mother in answer D is the only one who does not require Rhogam because she is Rh negative with an Rh-negative baby, eliminating the need for RhoGam administration.
4. Which of the following post-operative diets is most appropriate for the client who has had a hemorrhoidectomy?
- A. High-fiber
- B. Low-residue
- C. Bland
- D. Clear-liquid
Correct answer: Clear-liquid
Rationale: The correct answer is 'Clear-liquid.' After a hemorrhoidectomy, the client is usually started on a clear-liquid diet to allow the intestines to rest and promote healing. This diet helps prevent straining during bowel movements, which is crucial for recovery. Stool softeners are often included in the plan to avoid constipation. Once the client tolerates the clear liquids well, they can progress to a regular diet. High-fiber diet (choice A) is beneficial in the later stages of recovery to prevent constipation but is not typically the initial post-operative diet. Low-residue diet (choice B) and bland diet (choice C) are not appropriate for this type of surgery as they may not provide the necessary post-operative care and support needed for healing.
5. To remove hard contact lenses from an unresponsive client, what should the nurse do?
- A. Gently irrigate the eye with an irrigating solution from the inner canthus outward
- B. Grasp the lens with a gentle pinching motion
- C. Don sterile gloves before attempting the procedure
- D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens
Correct answer: Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens
Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.
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